IDENTIFYING INFORMATION AND REFERRAL STATEMENT

1. Include      description of client’s (individual, couple, family,c.) age, occupation,      marital status and any other significant identifying information such as      previous treatment at the Psychology Clinic (e.g., Mrs. M. is a 40 year      old, single parent of three children, who works as a bookkeeper. Had previously been seen at the Therapeutic      Clinic for one session. (See Intake      on file 1/07/80).
2. Indicate      the referral source, such as self-referral, referral by a physician, or      social agency, and if there was a specific reason for the referral (e.g.,      Mrs. M. was referred to the Therapeutic Clinic by the Family Resource      Center because of alleged neglect of her children).

PRESENTING COMPLAINT:
State briefly what is the most distressing at this time and use the client’s own words whenever possible using quotes. Indicate what kind of treatment they desire or expect, and what results they hope for (e.g., Mrs. M. would want her boyfriend involved in treatment, though he reportedly refuses to come in; Mrs. M. hopes to “get along better with him” and “take better care of my children.”).
HISTORY OF PRESENTING COMPLAINT:
Describe in chronological order (and with dates) the onset and development of the presenting complaint and how it is manifested.
(a) Onset – when the problem began to affect or interfere with the client’s daily living or became manifest to those around him.
(b) Identify the precipitation stresses (e.g., separation, loss of employment, etc.) and severity of stressors.
(c) Previous conditions, psychiatric hospitalizations and/or treatment which were similar to or the same as the presenting complaint (this information is often asked on insurance claim forms).
MEDICAL: Brief and mentioned if applicable. Note special medical problems present and any substance abuse. List current medications.
PERSONAL HISTORY: (Only if applicable) If personal history is not utilized, significant events or changes may be documented in Therapist Notes, Transfer Summary, or Closing Summary,
This should briefly include any relevant occurrence (developed chronologically) and can use the following headings as a guide:
(a) Birth and Infancy: Were there any difficulties or special circumstances (medical, adoption, frequent moves, etc.)
(b) Childhood: Overall adjustment and relationships to peers as well as academic performance (e.g., did above-average work in school and reported positive peer relationships).
(c) Adolescence: Further development including any behavioral changes, family circumstances, peer adjustment, education, and relationships with the opposite sex.
(d) History up to time of presenting complaint including vocational information, dating/sexual experiences, and marital relationship(s) if applicable. Note present living arrangement and significant socio-economic circumstances or influences.
CLINICAL DESCRIPTIONS, IMPRESSIONS, AND OBSERVATIONS:
Include (1) pertinent dynamic factors in the development of the presenting complaint, taking into account psychological aspects of the client’s life (e.g., family; employment, etc.), (2) appraisal of insight and motivation for treatment, and (3) level of functioning or impairment, including the client’s own strengths and resources.
Areas of functioning and/or impairment should focus on: (1) symptomatology, (2) productivity (employment; activities of daily living), (3) capacity for pleasurable experiences (hobbies; entertainment), (4) interpersonal relationships, (5) capacity to handle ordinary conflicts and stresses. Assess and record whether impairment or reactions in these areas are mild, moderate or severe.
Note any significant information which might mean the client is “at risk” (suicidal ideation, homicidal ideation, etc.).
[Where applicable briefly note and/or assess defenses, affect, behavior, personality style, traits, and patterns. In evaluating the client, take into consideration the mental status examination.]
MENTAL STATUS:
TENTATIVE DIAGNOSIS:
(1) According to DSM V, or (2) Dynamic formulation with clinical features, or (3) Reason for contact with the agency.
CASE FORMULATION & TREATMENT PLANNING RECOMMENDATIONS:
Case formulation is the bridge between clinical assessment and treatment planning. (See page 415 textbook). You attempt to synthesize all that has been learned about the patient’s past, so as to point the way to a better future
Several reasons for preparing a formulation: (1) To focus your thinking about the patent, (2) To summarize the logic behind your diagnoses, (3) To identify future needs for information and treatment, and (4) To present a brief summary of the patient.
State type of treatment utilized (e.g., crisis, insight-oriented, supportive, behavioral, psychotherapy, etc.), the treatment modality (e.g., estimated length of treatment, changes in modality, etc.). Include designation of the primary therapist(s) (e.g., Will be seen by the undersigned and Ms. M, in group therapy).
(a) Treatment focus and/or goals with specific reference to the client’s “reason for seeking treatment.”
(e.g., Initial treatment recommendation is individual psychotherapy on a once weekly basis. Therapy will focus on Mrs. M.’s presenting concerns around her relationship with boyfriend and child management issues. Couple treatment is possible in the future, but boyfriend presently refuses to attend sessions. Will work on symptom relief (early morning wakening) and increasing her ability for pleasurable experiences, etc.).